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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :

I. Identitas KlienNama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal

Pengkajian:

Alamat : Sumber Informasi :

II. Riwayat Kesehatan1. Diagnosa Medik:

………………………………………………………………………….................................…………………………………………………………………………………………………………………………

2. Keluhan Utama:……………..………………………………………………………………………….………....……………………….………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Riwayat penyakit sekarang: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................................................................................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Riwayat kesehatan terdahulu:a. Penyakit yang pernah dialami:………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………..…………………………………………………………………………………………b. Alergi (obat, makanan, plester, dll):………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................…………c.Imunisasi:………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d.Kebiasaan/pola hidup/life style:………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..…………………………………………………………………………………………………… …………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..…………………………………………………………………………………………………………..e. Obat-obat yang digunakan: ………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..…………..…………………………………………………………………………………………………………………………

5. Riwayat penyakit keluarga:

………………………………………………………………………….................................………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..……………………………………………………………………………………………………………

Genogram:

III. Pengkajian Keperawatan1. Persepsi kesehatan & pemeliharaan kesehatan

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..……………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..…………………………………………………………………………………………………

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2. Pola nutrisi/ metabolik (ABCD)- Antropometeri

…………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..……………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..…………………………………………………………

- Biomedical sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..……………………………………………………………………

- Clinical Sign : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………

………..………………………………………………………………………………………………………………..……………………………………………………………………Interpretasi :…………………………………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………..…………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………..……………………………………………………………………………………………………………..…………………………………………………

- Diet Pattern :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………..

3. Pola eliminasi: BAK

- Frekuensi :……………………………………………………………………………..- Jumlah :……………………………………………………………………………..

- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu- Lain : ……………………………………………………………………………..

BAB - Frekuensi :……………………………………………………………………………..- Jumlah :……………………………………………………………………………..- Konsistensi : ……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu - Lain : ……………………………………………………………………………..

Interpretasi :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Pola aktivitas & latihan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c.1. Aktivitas harian (Activity Daily Living)Kemampuan perawatan diri 0 1 2 3 4Makan / minumToileting Berpakaian Mobilitas di tempat tidurBerpindah Ambulasi / ROM

Keterangan :0 = ketergantungan total, tidak dapat berpartisipasi dalam aktivitas1 = membutuhkan pertolongan orang lain dan peralatan atau alat bantu2 = membutuhkan pertolongan orang lain untuk bantuan, pengawasan dan

pendidikan3 = membutuhkan peralatan atau alat bantu4 = mandiri penuh

Status Oksigenasi :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi kardiovaskuler :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Terapi oksigen :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

5. Pola tidur & istirahatDurasi :……………………………………………………………………………………………………Gangguan tidur :……………………………………………………………………………………….Keadaan bangun tidur :………………………………………………………………..……………Lain-lain :…………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

6. Pola kognitif & perceptualFungsi Kognitif dan Memori :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi dan keadaan indera : ……………………………………………………………………………………………………………………………………………………….....................................................................................................................................................................……………………………………...................................................……………………………………...........................................................................................................……………………………………...........................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

7. Pola persepsi diriGambaran diri :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………...........................................................................................................……………………………………...........................................................................................................Identitas diri :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...........................................................................................................……………………………………...........................................................................................................

Harga diri :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………...........................................................................................................……………………………………...........................................................................................................Ideal Diri :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………...........................................................................................................……………………………………...........................................................................................................Peran Diri :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………...........................................................................................................……………………………………...........................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………...........................................................................................................……………………………………...........................................................................................................

8. Pola seksualitas & reproduksiPola seksualitas ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...........................................................................................................Fungsi reproduksi …………………………………….................................................................................................................................................................................................................................................................................................................................................……………………………………...........................................................................................................…………………………………….......................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………...........................................................................................................……………………………………...........................................................................................................

9. Pola peran & hubungan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

10. Pola manajemen koping-stress……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

11. System nilai & keyakinan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………

IV. Pemeriksaan FisikKeadaan umum:……………………………………………………………..……………………………..........................................…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………........................................................................................................Tanda vital:

- Tekanan Darah : mm/Hg- Nadi : X/mnt- RR : X/mnt- Suhu : C

Interpretasi :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi) 1. Kepala

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2. Mata …………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Telinga.…………………………………………………………………………………….........................................……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Hidung………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5. Mulut………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. Leher………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. Dada.………………………………………………………………………………………...….…………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………… ……………………………………...........................................................................................................

8. Abdomen………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9. Urogenital………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

10. Ekstremitas………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

11. Kulit dan kuku………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

12. Keadaan lokal……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

V. Terapi

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VI. Pemeriksaan Penunjang & Laboratorium

………...........................2015

Pengambil Data,

(___________________________________________)

ANALISA DATA

NO DATA PENUNJANG ETIOLOGI MASALAH

RENCANA TINDAKAN KEPERAWATAN

No Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi Rasional

RENCANA TINDAKAN KEPERAWATAN

No Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi

CATATAN PERKEMBANGANDIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

CATATAN PERKEMBANGAN

DIAGNOSA:


CATATAN PERKEMBANGANDIAGNOSA:


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